Patient Safety Incident Response Framework

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To support the NHS to further improve patient safety, we are preparing for the introduction of a new Patient Safety Incident Response Framework (PSIRF), outlining how providers should respond to patient safety incidents and how and when a patient safety investigation should be conducted.

Due to additional pressures on the NHS at the current time, our PSIRF work with early adopters has been put on hold until further notice. We will look to publish revised timeframes for the introduction of the PSIRF on this page when we are able to.

The PSIRF is a key part of the NHS Patient Safety Strategy published in July 2019. It supports the strategy’s aim to help the NHS to improve its understanding of safety by drawing insight from patient safety incidents.

Working with early adopters

To test the PSIRF, we are first working with a small number of early adopters who are using an introductory version of the framework in their organisations. A list of the early adopters can be found at the bottom of this page.

This testing phase will be used to inform the creation of a final version of the PSIRF which we anticipate will be published in Spring 2021.

At that point, other providers of NHS funded care in England who are not early adopters will also begin adopting the new framework. All NHS organisations are expected to have transitioned to using the new framework from Autumn 2021.

Introductory version of the PSIRF

While we are not asking organisations other than the early adopters to transition to the PSIRF yet, we want to help providers outside of the early adopter areas to plan for this change. We have therefore published below the introductory version of the framework that is being tested. Organisations and local systems should review this document and begin to think about what they will need to do to prepare ahead of the full introduction of the PSIRF in 2021.

Until instructed to change to the PSIRF (likely from Spring 2021), non-early adopter organisations must continue to use the existing Serious Incident Framework.

Introductory version of the Patient Safety Incident Response Framework PDF, 1.1 MB

The introductory version of the Patient Safety Incident Response Framework that is being tested with early adopters.

Supporting guidance

Patient Safety Incident Response Plan (PSIRP) template DOCX, 183.6 KB

A template to guide local early adopter organisations in prioritising investigation quality over quantity

Patient Safety Incident Investigation Standards PDF, 399.6 KB

Standards for commissioners, boards and investigators in the commissioning, oversight, conduct and use of patient safety incident investigations

PSIRF implementation timescales

Our current timescale for the roll out and implementation of PSIRF across the NHS in England is as follows (dates are subject to change):

  • March 2020 – work begins with early adopters and PSIRF published as introductory guidance. Other providers continue to use the Serious Incident Framework
  • Spring 2021 – final PSIRF will be published reflecting our work with early adopters. All providers begin to transition to the PSIRF
  • By autumn 2021 - all parts of the NHS in England expected to be using the PSIRF

Patient safety investigation resources

We have also updated a range of resources to support NHS organisations to conduct patient safety incident investigations (PSIIs).

List of early adopters

We are working with groups of organisations in each NHS region as early adopters, together with one organisation that works nationally.

Listed by region, the early adopter organisations are:

East

  • Norfolk and Suffolk NHS Foundation Trust
  • East Suffolk and North Essex NHS Foundation Trust
  • Essex Partnership University Foundation Trust
  • West Suffolk NHS Foundation Trust
  • NHS Suffolk and North East Essex CCG/ICS

London

  • London Ambulance Service NHS Trust
  • North West London Collaboration of CCGs

Midlands

  • Chesterfield Royal Hospital NHS Foundation Trust
  • Derbyshire Community Health Services NHS Foundation Trust
  • Derbyshire Healthcare NHS Foundation Trust
  • Derbyshire Health United
  • University Hospital Derby and Burton NHS Foundation Trust
  • NHS Derby and Derbyshire CCG/STP

National

  • Care UK (Independent provider of healthcare in prisons)

North East and Yorkshire

  • Leeds Teaching Hospitals NHS Trust
  • NHS Leeds CCG

North West

  • East Lancashire Hospitals NHS Trust
  • NHS East Lancashire CCG

South East

  • Isle of Wight NHS Trust
  • NHS Isle of Wight CCG

South West

  • Cornwall Partnership NHS Foundation Trust
  • Royal Cornwall Hospitals NHS Trust
  • NHS Kernow CCG

Responding to patient safety incidents patient story videos

We have produced a series of patient story videos to be used as training resources for NHS organisations to demonstrate the impact the initial response to a patient safety incident and subsequent investigation has on the patient

  • Responding to patient safety incidents – Kathryn’s story

Kathryn talks about her experience following an incident where she was harmed when her cannula was not flushed following surgery, leaving her close to death and temporarily paralysed

  • Responding to patient safety incidents – Kathryn’s story

Kirsty talks about her experience following an incident where there were problems with care during the delivery of her third child following the administration of a Syntocinon drip.

  • Responding to patient safety incidents – Valerie's story

Valerie, a patient with Parkinson’s disease, talks about her experience following an incident where she was mixed up with another patient and given the wrong medication

Developing the PSIRF

Reports by the Public Administration Select Committee in March 2015; the Government’s response in July 2015; the Parliamentary and Health Service Ombudsman’s report in December 2015; the CQC’s report in June 2016, and the CQC’s report in Dec 2016 all identified shortcomings in the way patient safety incidents are investigated and learned from.

In response to these reports, in 2018 we conducted a widespread engagement exercise around the future of NHS patient safety investigation to gather thoughts and feedback to support us to develop the PSIRF to replace the existing Serious Incident Framework.

The future of NHS patient safety investigation: engagement feedback PDF, 1.7 MB

This document summarises the feedback received through our The future of NHS patient safety engagement activity.

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